Schedule of Dental
Co-payments
The following co-payments will
be charged to you by your CapDent primary care general dentist for covered
dental services. These co-payments do not apply when you receive treatment
from CapDent participating specialists. CapDent Specialists (including
orthodontists) will charge their usual fees, less a discount of 25
percent. In the High Option, you will also have the ability to use non-CapDent
participating specialists. If so, the co-payments shown will apply for the
services listed (referrals are necessary when using these other
Specialists). For orthodontic care, enrollees in all three options can be
treated by CapDent Orthodontists with a 25 percent discount off their
usual fee (24 months of coverage). High Option enrollees may also be
treated by non-CapDent Orthodontists if the Enhanced Orthodontia Benefit
was purchased by the employer. The Enhanced Orthodontia Benefit is not
available to groups with one or two insured employees. If so, your
co-payments will be $1,200 for children and $1,600 for adults (24 months
of coverage).
BENEFIT AND NETWORK CHART
|
Network |
Benefit |
| Low Option |
CapDent
Primary Dentists
CapDent Specialists |
Co-payment chart applies
Discount regular fees 25% |
| Medium Option |
CapDent
Primary Dentists
CapDent Specialists |
Co-payment chart applies
Discount regular fees 25% |
| High Option |
CapDent
Primary Dentists
CapDent Specialists
non-CapDent Specialists |
Co-payment chart applies
Discount regular fees 25%
Co-payment chart applies |
| ADA
Code |
Description |
LOW
OPTION
Co-payments** apply to CapDent
Primary Care General Dentists* |
MEDIUM
OPTION
Co-payments** apply to CapDent
Primary Care General Dentists* |
HIGH
OPTION
Co-payments** apply to CapDent
Primary Care General Dentists and non-CapDent Specialists |
|
Each
office visit |
$0 |
$5 |
$5 |
| 0150/0120 |
Oral
exams |
0 |
0 |
0 |
| 0210 |
Full
mouth X-rays |
0 |
0 |
0 |
| 0220 |
Single
films/each add'l |
0 |
0 |
0 |
| 0330 |
Panoramic |
0 |
0 |
0 |
| 1110 |
Prophylaxis |
0 |
0 |
0 |
| 1230 |
Topical
flouride |
0 |
0 |
0 |
| 1351 |
Sealants,
per tooth |
Not
covered |
20 |
0 |
| 2140 |
Amalgam
one |
20 |
0 |
0 |
| 2150 |
Amalgam
two |
35 |
0 |
0 |
| 2160/2161 |
Amalgam
three/four |
50 |
0 |
0 |
| 2951 |
Pin
retention |
10 |
0 |
0 |
| 2330 |
Composite
one |
25 |
0 |
0 |
| 2331 |
Composite
two |
40 |
0 |
0 |
| 2332/2335 |
Composite
three/four |
55 |
0 |
0 |
*CapDent Specialists will charge their
usual fees, less a discount of 25 percent.
**Not a comprehensive list of services and co-payments.
The High Option Plan requires $150 per service co-pay per procedure for
all crowns (other than stainless steel), all units of bridgework,
dentures, molar root canals and periodontal surgery. Not all services
which require this co-pay are listed above.
|
